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Ethicon Application Form

This document is an application for funding from the Ethicon Foundation. It requests basic contact information from the applicant such as name, address, email, training number, and specialty. It also asks for details of the proposed visit such as location, dates, department, and intended learning objectives. Additional requirements include letters of support, confirmation from the host institute, and evidence of approval from the appropriate regulatory body if the visit is to count towards training requirements. The applicant is asked to provide education history, career details, publications, estimated expenses, other funding sources, and the total amount requested.

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41 views5 pages

Ethicon Application Form

This document is an application for funding from the Ethicon Foundation. It requests basic contact information from the applicant such as name, address, email, training number, and specialty. It also asks for details of the proposed visit such as location, dates, department, and intended learning objectives. Additional requirements include letters of support, confirmation from the host institute, and evidence of approval from the appropriate regulatory body if the visit is to count towards training requirements. The applicant is asked to provide education history, career details, publications, estimated expenses, other funding sources, and the total amount requested.

Uploaded by

POILKKJ
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Application for Ethicon Foundation

Fund
Full Name:
Current Address:
Date of Birth:

Email:

Tel No:

Training Number:

Country and institute where visit will take place:

Date of Visit:

Length of Visit:

Specialty:

Title of Study:

Visit details i.e. why are you going, which department will you visit, what experience are you
hoping to gain: (Please do NOT include attachments with your application)

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Do you hold the FRCS (England) YES/NO Date awarded: FRCS/MRCS
(or from 1998) the MRCS (England)? (Please circle) (Please circle)

Fellowship/Membership Number:
……………………

If you are a consultant, what date were you Date appointed:


appointed?

Have you applied for any other grants:


If so, please state:

Education and Qualifications:

Career to date:

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List of Publications:

Financial Statement

Please give details of:


i) Expenses incurred with special reference to the cost of personal travel
ii) Financial resources already available
iii) Other grants or fellowships applied for

Total amount applied for:

Name of current Head of Department referee:

Name of independent referee:

Save this application form as a Word Document.

Please submit the following electronically to [email protected]

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1. Application form
2. A letter of support from the head of department, or consultant, under whom the applicant
is currently working
3. A letter of support from another, independent referee
4. Confirmation from the Institute you are visiting.

UK trainees must produce confirmation/evidence of prospective approval from the GMC if


the post is to count towards the award of a Certificate of Completion of Training (CCT).

Signature…………………………………………………………………Date……………………………………..

The information you have given on this form will be held by the Research Department of the Royal
College of Surgeons of England on a compartmented secure server in accordance with the General Data
Protection Regulation (GDPR), and will be used only in connection with the purposes that you originally
contacted us for. The information is kept by The Royal College of Surgeons of England. It will be
circulated to reviewers and available to the Research Committee and all members of staff in the
Research department, and will not be shared throughout the wider organisation unless instructed
otherwise.

Research Department
Royal College of Surgeons of England
[email protected]

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